The Collaborative Problem Solving Approach ... - Think:Kids

PERSPECTIVES The Collaborative Problem Solving Approach: Outcomes Across Settings Alisha R. Pollastri, PhD, Lawrence D. Epstein, PhD, Georgina H. Heath, BSc, and J. Stuart Ablon, PhD In the last decade, Collaborative Problem Solving (CPS) has become a popular approach to managing the challenging behaviors of children and adolescents, and has established a growing evidence base for reducing oppositional behavior and related outcomes. In contrast with standard behavioral methods that provide incentives for meeting adult expectations, CPS focuses on identifying and treating lagging cognitive skills that interfere with children’s ability to meet these expectations. Since the majority of CPS outcomes have been evaluated in clinical and educational settings as part of internal quality-improvement efforts, only a small proportion of these findings has been published in peerreviewed academic journals. Here, we describe the CPS approach and provide a summary of all known published and unpublished findings related to its implementation in outpatient, inpatient, residential, juvenile justice, and educational settings. Finally, we provide specific recommendations for future research on the model. Keywords: children, Collaborative Problem Solving, externalizing, family, inpatient, juvenile justice, oppositional defiant disorder, residential, school, Think Kids

E

xternalizing behaviors, including temper outbursts, defiance, deceit, destruction of property, and verbal or physical aggression are relatively common in children, with 5% to 13% of mothers of preschoolers reporting that their children exhibit moderate to severe externalizing behaviors,1–3 and epidemiologic studies reporting a 19% lifetime prevalence of childhood disruptive behavior disorders.4 Children exhibiting externalizing behaviors are frequently referred to as oppositional, challenging, explosive, difficult, defiant, or aggressive. They may carry diagnoses of attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), oppositional defiant disorder (ODD), or intermittent explosive disorder, or these challenging behaviors may be one part of a larger set of symptoms identified as a mood, anxiety, or developmental disorder. The negative impact of children’s externalizing symptoms on their caregivers and the community is significant. For example, parents of externalizing children often experience clinically significant levels of stress,5 and student

From Harvard Medical School (Drs. Pollastri, Epstein, and Ablon); Department of Psychiatry, Massachusetts General Hospital, Boston, MA (Drs. Pollastri, Epstein, and Ablon); St. Andrew’s Healthcare, Northampton, UK (Ms. Heath). Original manuscript received 30 October 2012; revised manuscript received 12 March 2013, accepted for publication 8 April 2013. Correspondence: Alisha R. Pollastri, Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Email: apollastri@ partners.org © 2013 President and Fellows of Harvard College DOI: 10.1097/HRP.0b013e3182961017

188

www.harvardreviewofpsychiatry.org

misbehavior is consistently identified as a primary source of teacher stress.6–8 This stress is exacerbated when teachers are not adequately trained or have insufficient resources available to work effectively with externalizing children.9 Furthermore, managing challenging behavior can cause a strain on both the relationships and interactions between children and adult caregivers.10,11 Considering the individual and familial costs of externalizing behaviors, as well as societal costs associated with government-subsidized juvenile detention centers, specialized school programs, residential facilities, inpatient psychiatric units, and outpatient community agencies, it is no surprise that significant research has been devoted to evaluating the efficacy of interventions targeted at reducing these behaviors. Clinical and educational settings that specialize in treating disruptive behavior disorders have historically used methods of intervention that are based on operant theories of behavior modification.12 These methods, including point and level systems, quiet rooms, physical restraints, and seclusion, are typically believed to help patients develop greater self-control and coping, to increase positive behavior, and to decrease negative and aggressive behavior.13 However, the efficacy of some of these behavioral methods has recently been called into question.14–17 Of particular concern recently has been the use of physical restraint and seclusion in managing externalizing behavior. First, there is growing evidence that restraint and seclusion procedures may actually heighten aggressive behavior in children.18 Second, these procedures can be dangerous for both the patients and staff involved18,19 and, in Volume 21 • Number 4 • July/August 2013

Copyright @ 2013 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.

Collaborative Problem Solving

very extreme cases, have led to death.20,21 As a result, legislation has been introduced with the goal of reducing or eliminating these types of restrictive interventions.22,23 Interestingly, while the motivation to reduce the use of restrictive interventions has been to improve educational and mental health services, one analysis in a single inpatient agency found an annual cost savings of over $1 million resulting from the decreased use of physical, mechanical, and medication-based restraint.24 Thus, decreasing use of restrictive interventions may make sense not only from a psychological, but also from an economic, perspective. Due to the potential for tragic outcomes related to restrictive behavioral interventions, the last decade has seen a movement away from these traditional behavioral practices and toward the development of alternative methods that pose fewer risks to staff and patients and that effectively decrease externalizing behaviors. One of these new approaches is Collaborative Problem Solving (CPS). As described by Drs. Ross Greene and J. Stuart Ablon in their treatment manual,25 the CPS model reconceptualizes the reasons for children’s externalizing behaviors, and offers specific techniques for intervention. The CPS approach has been implemented in a variety of outpatient, inpatient, residential, juvenile justice, and school settings, and there have been multiple formal and informal attempts to evaluate and validate this treatment model. In this article, we first describe how CPS differs from conventional approaches in conceptualizing and treating externalizing disorders in children. Next, we summarize all known published and unpublished evaluations of the treatment model from the time of its introduction up through 2012. Finally, we make recommendations for future comprehensive evaluation of the CPS model, with the ultimate goal of improving the treatment of childhood externalizing disorders.

CONVENTIONAL INTERVENTIONS FOR EXTERNALIZING BEHAVIORS: OPERANT APPROACHES The procedures and tools that are typically used to reduce oppositional behavior are based upon common beliefs about its causes. Behavioral theories suggest that children learn to behave disruptively because those behaviors effectively get them something (e.g., attention) or allow them to avoid something (e.g., work). This understanding assumes that children have control over whether they behave in compliance with, or in opposition to, adult expectations. This understanding also implies that these children will behave well if they believe that good behavior will result in a desired outcome. Consistent with this theory, many common interventions for disruptive behavior aim to motivate oppositional children to want to behave better. In sum, behavioral theories posit that children will do well if they want to, and corresponding interventions aim to increase children’s motivation such that they will want to behave well. Harvard Review of Psychiatry

Based on this understanding, many conventional behavioral interventions with externalizing children have sought to motivate compliant behavior through operant methods. Such methods date back to the famous behaviorist studies of B. F. Skinner (1904–90), who demonstrated that target behaviors could be elicited, and unwanted behaviors diminished, through an intensive and consistent menu of rewards and punishments. Behavioral approaches, including reward charts and time-outs, are now used worldwide and are applied in a wide range of settings. Indeed, considerable empirical research supports a number of treatment approaches that use operant behavioral methods to increase compliance with adult expectations.26 Behavioral approaches typically achieve two primary objectives related to the management of behavior. First, they reinforce basic lessons, such as what the acceptable and unacceptable behaviors are in a given situation. Second, they facilitate extrinsic, or external, motivation. The motivation to receive a reward or avoid a punishment can tip the scales in favor of exhibiting a desired behavior, assuming one has the skills needed to perform that behavior. As an example, a recent meta-analysis suggests that conventional behavioral approaches can be moderately successful in decreasing externalizing behavior, though effect sizes are not as robust as once assumed,27 and positive effects may not be sustained in the long term.14,16,28 While behavioral methods are useful in some cases, problems arise when attempting to use these operant approaches with children who know what is expected of them and who are motivated to do well, but who lack skills to do so due to deficits in impulse control, frustration tolerance, flexibility, problem solving, or other adaptive skills. For children who are aware of the consequences of their maladaptive behaviors but who lack the skills to inhibit these behaviors, the operant approach falls short. In fact, these approaches can sometimes do more harm than good: first, by increasing behavioral performance only in response to promise of reward; second, by negatively affecting the self-esteem of children who want to do well but lack the skills to do so, and who are told repeatedly that they are failing to meet expectations because they are not trying hard enough; and third, by increasing power struggles between adults and children that can be detrimental to the relationship.29,30 In sum, through increase of motivation, operant approaches can make the possible more probable, but they simply cannot make the impossible possible. In an attempt to rectify the shortcomings of traditional operant approaches, a new approach to understanding challenging children has emerged: Collaborative Problem Solving.

AN UNCONVENTIONAL APPROACH: FOCUS ON SKILLS, NOT BEHAVIORS CPS is a conceptual and therapeutic model that posits that chronic and severe externalizing behavior is the product of lagging cognitive skills that interfere with a child’s ability www.harvardreviewofpsychiatry.org


189

A. R. Pollastri et al.

to comply with adult expectations. Consider this: in order to meet adult expectations, a child must have an adequately developed set of cognitive skills allowing him to accurately comprehend and interpret the expectations, to flexibly respond to different expectations in different situations, to consider a range of responses, to predict consequences of each of those responses, to express his or her needs or difficulties in meeting expectations, and to tolerate frustration in the face of unexpected results. CPS asserts that if a child is lacking one or more of these skills, he or she will be unable to adaptively respond to demands and that, as a result, maladaptive behavior (defiance, outbursts, and so on) will ensue. Therefore, contrary to the belief that “children do well if they want to”—which underlies most behavioral approaches and also corresponding interventions that focus on increasing motivation—the philosophy of CPS is that “children do well if they can.” Analogous to the contemporary view of children with learning disabilities who are performing below their potential in academic areas, CPS asserts that children who are not successful in complying with behavioral demands have one or more skill deficits in critical areas such as flexibility, social perception, executive functioning, language processing, or emotion regulation. Thus, in contrast to behavioral approaches, the corresponding intervention focuses on improving these skills, rather than on increasing the motivation to comply. In fact, an underlying assumption of the CPS model is that all children start out motivated to comply, until experience teaches them that they do not have the skills to meet the demands; motivation wanes as a direct result.

CPS IN BRIEF: IDENTIFYING AND TRAINING LAGGING SKILLS Under the CPS approach, externalizing behaviors are treated in much the same way as any other learning disability. For each child, specific skill deficits are identified, along with the situations in which these lagging skills cause difficulty meeting adult expectations. Then the intervention assists the child in developing the skills that are lagging. This skill building occurs in natural settings through problem solving and is tailored to the child’s development level. As skills improve, externalizing behaviors are no longer triggered, and thus decrease. Identifying Lagging Skills In order to assess the specific cognitive-skills deficits for a particular child, it is first necessary to identify the demands or expectations that trigger their externalizing behaviors. Because the same challenging behavior (e.g., verbal outbursts) could be caused by a wide range of lagging skills, the specific type of challenging behavior is of little importance. The focus is on identifying the demands that trigger the behavior (e.g., transitions or spelling homework). Once a list of triggers is identified, the caregiver or clinician can use this list to inform hypotheses about lagging skills. For 190


example, a child who frequently overturns his or her school desk (the challenging behavior) in response to the end of free time and the start of work (the trigger) may have difficulty with transitions/set-shifting (executive functioning) or with tolerating frustration (emotion regulation). Use of parent-report measures such as the Thinking Skills Inventory can aid in identifying triggers and lagging skills (originally available as the Pathways Inventory in the CPS treatment manual;25 an updated version is available upon request from the present authors). Training Lagging Skills Skill development in the CPS model occurs through the process of collaborating with the child to solve chronic problems in a more adaptive manner. After identifying the situations in which externalizing behaviors are triggered by demands that overwhelm the child’s skills, the adult decides, for each situation, which of three ways to respond. In the CPS approach, these are named Plan A, Plan B, and Plan C. Plan A is used when adults pursue their original expectation by imposing their will upon the child, despite understanding that doing so may trigger externalizing behavior. For example, due to safety concerns, the adult might say, “If you don’t put that life jacket on, you will not be able to go in the water.” The adult has decided that this is a nonnegotiable situation and that this instruction must be followed; thus, he or she is using Plan A. Plan C is used when the adult chooses to withdraw the expectation, at least for a short time, in order to decrease externalizing behavior (e.g., by allowing the child to continue in free time while the rest of the students transition to work). This approach can be useful in stabilizing the situation while prioritizing other problems. Of note, Plan C is a preemptive strategy, communicated ahead of time to the child and should not be confused with “giving in,” which occurs when an adult pursues an expectation only to drop it later in an attempt to reduce the challenging behavior that ensues. In treatment settings, deciding which expectations to pursue and which to temporarily suspend is part of individualized treatment planning. Plan B—a seminal element of CPS—is used when the adult attempts to solve the problem collaboratively with the child. Implementation of Plan B consists of three components, performed sequentially. In the first component, the adult gathers information in order to gain a clear understanding of the child’s concerns about a particular recurring problem or issue (e.g., “I don’t like stopping free time when I’m in the middle of reading, because it’s hard for me to find my place again later.”) In the second, the adult states his or her concern or perspective (“My concern is that we need to move on to math at that time. I don’t want you to miss out on the beginning of math, because it will be hard to catch up later.”) When both the child’s and adult’s concerns are clear, the third component can be implemented: the Volume 21 • Number 4 • July/August 2013


Collaborative Problem Solving

adult and child brainstorm solutions that will address both their concerns. The child is given the first opportunity to generate a solution (e.g., “What if you warn me when we have a few minutes left, so I can find a good stopping point?”). No solutions are dismissed outright, and the adult helps the child to think through whether each solution addresses the concerns of both parties and whether it is realistic and feasible. Plan B is successfully completed when both adult and child have agreed on a mutually satisfactory and realistic solution. This process, however, is iterative; after a Plan B conversation, the child and adult implement the solution and return to discuss whether it was successful. If it was not, they discuss what other concerns arose, and they try again with another solution until they have found one that works. In CPS, the development of lagging skills are taught implicitly through the Plan B problem-solving process. The adult’s empathy and understanding in component 1, along with the child’s practice of empathy and understanding in component 2, teach the child to take another person’s perspective, to clarify and express his or her own concerns, and to separate affect (all of which build skills in social thinking, language processing, and emotion regulation). Guided brainstorming of solutions in component 3 trains the child to solve problems by generating solutions and by anticipating and considering the likely outcomes (which builds cognitive flexibility and executive-functioning skills). Thus, with Plan B, an adult can achieve five main objectives that are frequently targeted in the treatment of externalizing disorders: increasing adherence with adult expectations, reducing externalizing behaviors, creating (or restoring) a helping relationship between the adult and child, resolving chronic problems, and identifying and teaching lagging skills.

SUMMARY OF RESEARCH RESULTS BY SETTING The CPS approach was developed by staff in the Department of Psychiatry at Massachusetts General Hospital (MGH) in Boston, Massachusetts, and the first book describing the approach was published in 1998.31 Since then, clinical staff from MGH have provided training and consultation to hundreds of schools, hospitals, and residential treatment centers. Most frequently, all agency or school staff members receive intensive training in the model, followed by ongoing consultation to a core team that oversees the implementation of CPS within their facilities. Following is a summary of all known attempts to evaluate the efficacy of the CPS approach. Published articles describing CPS treatment outcome studies were identified through the following methods: (1) computerized searches of electronic databases for articles published between 1998 and 2012 using keywords “collaborative problem solving,” and (2) a manual search of the reference lists of articles obtained through the database searches. After excluding articles that use the term collaborative problem solving to describe a process unrelated Harvard Review of Psychiatry

to the treatment model under discussion here, a total of nine peer-reviewed articles remained, which discussed six unique empirical studies. A summary of these six studies, including demographics of research participants and major findings, is presented in Table 1.32–40 In addition to these six published studies, we include in this article unpublished results from outcomes studies implemented as part of internal qualityimprovement efforts at a number of schools and agencies not included in the published studies. Since MGH staff have provided consultation to all of the schools and agencies that have adopted CPS as an organization-wide treatment model, these outcomes have been reported back to MGH staff via personal communication, for the purpose of informing model development. These unpublished outcomes are included here in the interest of informing future evaluation and intervention efforts, and should be interpreted with appropriate caution. Outpatient Research: Published The first study of CPS in an outpatient setting was a randomized, controlled trial conducted at Massachusetts General Hospital.32,33 In this study, families (n = 47) were randomized into two groups, and received individual family treatment either with CPS (n = 28) or parent management training (PMT; n = 19), a behavioral family therapy model that focuses on modifying parental discipline to help reduce oppositional behavior by teaching and motivating children to be more compliant. All enrolled children had a diagnosis of oppositional defiant disorder and significant mood symptoms; many children also displayed subthreshold features of conduct disorder. In this trial, CPS produced significant improvements in numerous domains of functioning, including improvement in parents’ perceptions of competence and stress (as measured by the Parenting Stress Index) and in parent-child interactions (as measured by the Parent-Child Relationship Inventory), as well as a reduction in oppositional behaviors (as measured by the ODD Rating Scale). Although in many cases, improvements experienced by families receiving CPS were greater than those experienced by families receiving PMT, differences between conditions were not statistically significant, possibly due to the small sample size. There was, however, a statistically significant difference between conditions on the Clinical Global Improvement scale, for which children in the CPS condition were rated by both therapists (measured post-intervention) and parents (measured at follow-up) as improving more than children in the PMT condition, The authors concluded that the CPS model was a worthy alternative to behavioral models such as PMT.32,33 Of note, this study remains the only randomized, controlled trial that has been published on CPS to date, though a large-scale replication including 150 families is currently under way. Preliminary data from this replication indicate that, consistent with the original trial, individuals in the CPS group achieved clinically and statistically significant improvements in ODD symptoms, performing better than www.harvardreviewofpsychiatry.org


191

192


Inpatient psychiatric

Outpatient parent therapy group

Martin et al. (2008)36 Also discussed in Mohr et al. (2009)37

Epstein & SaltzmanBenaiah (2010)38

Alternative day school

19 parents of 12 children

Inpatient psychiatric

Greene et al. (2006)34 Also discussed in Regan et al. (2006)35

Schaubman et al. (2011)39

755

Outpatient family therapy

Greene et al. (2004)32 Also discussed in Greene et al. (2003)33

16

Not reported

47

Setting

Publication(s)

n

Grades 7–8

6–12

3–15

3–12

4–13

Age

Children in need of alternative day school Other demographics not reported

83% male Tourette’s/tic disorder + ODD, but not CD All had comorbid ADHD

65% boys with adjustment, anxiety, bipolar, depressive, hyperactivity, psychosis, or other Average stay 29 days

74% male 95% referred for “out-of-control behavior” 80% severe trauma histories Average stay 14 days

68% male ODD + affective dysregulation (minimum subthreshold MDD or BD)

Available child characteristics

Pre/post, within subjects Quasi-experimental comparison

Pre/post, within subjects


Teacher stress decreased significantly in multiple stress domains; effects stronger for teachers with highest fidelity Discipline referrals decreased significantly; effect generalized to the whole school (n = 100), not just the target children

Eight teachers attended 12 hours of CPS training & received weekly 75-minute consultations for 8 weeks; also received individual support & coaching as needed

Continued on next page

High treatment fidelity, attendance, retention, homework completion, & satisfaction in group attendees Disruptive behaviors decreased significantly but generally stayed in clinically significant range ODD diagnostic scores improved by mothers’ report Mothers’ parenting stress decreased

Restraints decreased from 263/year to 7/year Seclusions decreased from 432/year to 133/year Durations also decreased significantly

Restraints decreased from 281 events in the 9 months before intervention to 1 event during a 15-month follow-up Short holds decreased from 100+/month to